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To rediscover the olfactory cleft
Poster No.:
C-1701
Congress:
ECR 2010
Type:
Educational Exhibit
Topic:
Head and Neck
Authors:
P. Henrot , P. Gallet , B. Grignon , T. Georgel , R. Jankowski ;
1
2
1
2
2
2
2
Vandoeuvre-lès-Nancy/FR, Nancy/FR
Keywords:
olfactory cleft, woodworker's adenocarcinoma, sinus anatomy
DOI:
10.1594/ecr2010/C-1701
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Page 1 of 65
Learning objectives
To be familiar with the anatomy and radioanatomy of the olfactory cleft
To review the radiologic specific signs of tumors of the olfactory cleft
To be familiar with the main types of tumors arising in the olfactory cleft
Images for this section:
Page 2 of 65
Page 3 of 65
Fig. 1: The nasal airstream passes for preference along the floor of the nose and
the inferior meatus during quiet respiration. Two physiologically different zones are
encountered in the nasal cavity: -a wide zone conducting the high speed airflow : the
respiratory cleft (yellow area) -a narrow zone conducting a low speed airflow toward the
olfactory region : the olfactory cleft (red area) The inferior limit of the olfactory cleft is
above the inferior end of the middle turbinate
Fig. 2: Coronal CT scan depicts an enlargement of the left olfactory cleft (red line), a
bulging of the septum (green line)beyond the midline (blue line), and a lateral tilting of
the conchal lamina (yellow line). The origin of the tumor is inside the olfactory cleft and
not in the ethmoid.
Page 4 of 65
Fig. 3: Axial T2-weighted image demonstrate a different signal between the tumor
(asterisk)in low signal and the ethmoidal labyrinth opacified by obstruction (yellow arrow).
The origin of the tumor is inside the olfactory cleft and not in the ethmoid.
Page 5 of 65
Fig. 4: Man of 85y., reporting nasal obstruction for many years. CT shows evidence of an
obstruction of both olfactory clefts (red asterisks). The ethmoidal labyrinth appears with
a normal air content ( yellow arrows). Biopsy revealed a bilateral respiratory epithelial
adenomatoid hamartoma (REAH).
Page 6 of 65
Fig. 5: Man of 72y. suffering from an unilateral left nasal obstruction for 2 years. Biopsy
of a left nasal mass demonstrates an inverted papilloma. The mass fills the posterior half
of the left olfactory cleft (red arrow) and involves the respiratory cleft inferiorly (yellow
arrow).
Page 7 of 65
Background
Tumors of the olfactory cleft in the literature
There is no reported dedicated work dealing with imaging findings of tumors of the
olfactory cleft in the radiological literature.
In the literature dealing with imaging of tumors of the sinonasal cavities and nasal
cavity, the actual anatomic site of origin reported may not always be accurate of well
documented.
Although some references reported locations of tumors on the lateral wall of the nasal
cavity or septum, olfactory cleft is not specifically mentioned.
However …some tumors are known to arise in the olfactory cleft (such as olfactory
neuroblastoma), some tumors have been reported to involve the upper nasal cavity (such
as melanoma), and some tumors frequently involve the lateral wall of the nasal cavity
(such as inverted papilloma).
Moreover, new concepts were recently reported:
•
•
Woodworkers adenocarcinoma arises in the olfactory cleft (Jankowski et al
Rhinology 2007; 45: 308-14).
Respiratory Epithelial Adenomatoid Hamartoma (REAH) may be found in the
OC in patients suffering from nasal polyposis.
Definition of the olfactory cleft is controversial.
For some authors, the olfactory cleft corresponds to the olfactory region, covered by the
olfactory mucosa, featuring the cribriform plate and 1 cm² on each side, on the lateral
nasal wall and on the septal wall.
For most authors the olfactory cleft is defined according to a physiological approach
taking account the nasal airstream. Also, the air passes for preference along the floor of
the nose and the inferior meatus during quiet respiration.
Two physiologically different zones in the nasal cavity can thus be distinguished (fig.1):
on page 10
•
A wide zone conducting the high speed airflow : the respiratory cleft
Page 8 of 65
•
A narrow zone conducting a low speed airflow toward the olfactory region :
the olfactory cleft
In this concept, the inferior limit of the olfactory cleft corresponds to the inferior end of
the middle turbinate.
Radioanatomy of the olfactory cleft (1)
The roof is subdivided into three parts (fig.2): on page 12
-The anterior (nasal) part corresponds to the inferior edge of the nasal spine of the frontal
bone and nasal bone
-The middle (ethmoidal) part corresponds to the cribriform plate
-The postérior (sphenoidal) part corresponds to the ethmoidal process of the sphenoid
In the coronal plane, the roof of the olfactory cleft is located lower than the ethmoidal
roof (fig.3). on page 12
The anterior wall is a virtual frontier between nasal vestibule and the olfactory cleft (fig.4).
on page 14
The posterior wall corresponds to the anterior wall of the sphenoid(fig.4). on page 14
The lateral wall, called turbinal wall of the ethmoidal labyrinth, is subdivided into two
parts:
•
•
the superior part corresponds to the conchal lamina, a bony lamella that
gives insertion to the middle (fig.5) on page 14 , superior (fig.6) on page
16 and supreme turbinates (fig.7) on page 18 . The conchal lamina
joins the ethmoidal roof above the cribriform plate and its segment above the
cribriform plate is called lateral lamella of the intracranial olfactory groove
(fig.8) on page 20 .
the inferior part corresponds to the middle turbinate (fig.9) on page 22
The internal wall of the olfactory cleft features the nasal septum (fig.10) on page 24 .
The inferior wall is virtual, below the inferior end of the middle turbinate (fig.10) on page
24 .
Surrounding anatomic structures are: (fig.11) on page 26
Page 9 of 65
-above: the intracranial olfactory groove and anterior cranial fossa
-laterally the ethmoid labyrinth and then the orbit
-medially the perpendicular plate covered by septal perichondrium-periosteum and the
contralateral nasal cavity
Images for this section:
Page 10 of 65
Page 11 of 65
Fig. 1: The nasal airstream passes for preference along the floor of the nose and
the inferior meatus during quiet respiration. Two physiologically different zones are
encountered in the nasal cavity: -a wide zone conducting the high speed airflow : the
respiratory cleft (yellow area) -a narrow zone conducting a low speed airflow toward the
olfactory region : the olfactory cleft (red area) The inferior limit of the olfactory cleft is
above the inferior end of the middle turbinate
Fig. 2: The roof of the olfactory cleft is divided in three parts: Anterior (nasal) part (red
arrows): nasal bone (1), nasal spine of the frontal bone (2) and internal wall of the frontal
sinus (3) Middle (ethmoidal) part : cribriform plate (blue arrows) Postérior (sphenoid) part :
ethmoidal process of the sphenoid (green arrow)
Page 12 of 65
Fig. 3: In the coronal plane, the roof of the olfactory cleft (blue arrow) is located lower
than the ethmoidal roof (yellow arrow)
Page 13 of 65
Fig. 4: The anterior wall is a virtual frontier between nasal vestibule and the olfactory cleft
(red line). The posterior wall corresponds to the anterior wall of the sphenoid (yellow line).
Page 14 of 65
Page 15 of 65
Fig. 5: Coronal CT scan of the lateral wall, called turbinal wall of the ethmoidal labyrinth.
The superior part corresponds to the conchal lamina (in red), a bony lamella that gives
insertion to the middle (green arrow), superior and supreme turbinates.
Page 16 of 65
Page 17 of 65
Fig. 6: Coronal CT scan of the lateral wall, called turbinal wall of the ethmoidal labyrinth.
The superior part corresponds to the conchal lamina (in red), a bony lamella that gives
insertion to the middle, superior (yellow arrow)and supreme turbinates.
Page 18 of 65
Page 19 of 65
Fig. 7: Coronal CT scan of the lateral wall, called turbinal wall of the ethmoidal labyrinth.
The superior part corresponds to the conchal lamina (in red), a bony lamella that gives
insertion to the middle, superior and supreme turbinates (blue arrow).
Page 20 of 65
Page 21 of 65
Fig. 8: Coronal CT scan of the lateral wall, called turbinal wall of the ethmoidal labyrinth.
The conchal lamina joins the ethmoidal roof above the cribriform plate. The segment
above the cribriform plate is called lateral lamella of the intracranial olfactory groove
(yellow arrow).
Page 22 of 65
Page 23 of 65
Fig. 9: Coronal CT scan of the lateral wall, called turbinal wall of the ethmoidal labyrinth.
The inferior part of the turbinal wall corresponds to the middle turbinate (yellow arrows).
Page 24 of 65
Page 25 of 65
Fig. 10: The internal wall of the olfactory cleft features the nasal septum (yellow thisk line).
Fig. 11: Anatomic structures surrounding the olfactory cleft are: -above: the intracranial
olfactory groove (red arrowhead) and anterior cranial fossa -laterally the ethmoid labyrinth
(blue arrow) and then the orbit -medially the perpendicular plate covered by septal
perichondrium-periosteum (green arrowhead) and the contralateral nasal cavity
Page 26 of 65
Imaging findings OR Procedure details
The reported imaging findings in the literature are relative to tumors of the
sinonasal cavities or nasal cavities without any specific mention to the olfactory
cleft:
-Mass (CT-MR)
-Variable signal in T1 and T2-weighted images (MR), often low signal on T2
-Intratumoral calcifications or entrapped bone (CT)
-Bone erosion of sinonasal walls, orbit and cribriform plate, rarely sclerotic reaction (CT)
-Opacification of sinuses by obstruction (more reliably depicted with MR than CT)
-Inflammatory dural changes, neoplastic dural invasion or anterior cranial fossa invasion
(MR)
-Subperiosteal extraconal invasion or intraorbital invasion (CT-MR)
-Perineural spread along trigeminal nerve branches (MR)
A new concept has been recently reported: wood-workers adenocarcinoma (WAC)
arises inside the olfactory cleft and not in the ethmoid.
Woodworker's adenocarcinoma was classically described as arising in the ethmoid (2,3)
From endoscopic surgical observations, Jankowski et al. reported that WAC arise in
the olfactory cleft and grow out in the nasal cavity like polyp neoplasm and, even after
reaching big volume, many of them do not invade, but just displace and push out the
surrounding structures, ie the nasal septum and the turbinate wall of the ethmoidal
labyrinth. (4)
These findings of endoscopic surgery were confirmed by radiologic findings in a
study from Georgel et al (5).
Page 27 of 65
In this study, CT of 20 consecutive woodworker patients treated for an adenocarcinoma
with endoscopic surgery were compared with CT of 33 control patients.
The olfactory cleft was significantly wider in woodworker's adenocarcinoma than in
control patients (15.12 +/-4.52 mm vs 3.28 +/-0.68, p < 0.001)
The septum was significantly deviated from midline in woodworker's adenocarcinoma
(-4.58 +/-3.05 mm vs 0.51 +/- 0.98 p < 0.001).
The conchal lamina angle with vertical midline was significantly higher in woodworker's
adenocarcinoma (39.76°+/-13.83 vs 0.45°+/-2.13, p < 0.001). The lateral tilting of the
turbinal wall of the ethmoidal labyrinth demonstrates that the site of origin of the
adenocarcinoma is inside the olfactory cleft and not inside the ethmoidal labyrinth.
(case 1 : fig.1-5 , case 2 : fig.6-9 , case 3 : fig.10-16)
MR could also demonstrate the site of origin of the adenocarcinoma inside the
olfactory cleft by showing evidence of:
-A mass of the olfactory cleft
-A lateral tilting of the conchal lamina
-A septal bulging
-An absence or only partial tumoral involvement of the ethmoid labyrinth containing:
•Air (low signal on T1-T2)
•Mucosal inflammatory thickenning
•Opacification of sinuses by obstruction (high signal T2, no enhancement after
gadolinium)
•Preservation of the ethmoidal cells under the ethmoidal roof even in large tumors
Other tumors could usually or unusually arise in the olfactory cleft
Respiratory epithelial adenomatoid hamartoma (REAH)
Page 28 of 65
This lesion was described in 1995 by Wenig and Heffner, and previously reported as
rare (6).
However it may be more frequent and, despite initial descriptions localized HERA on the
nasal septum, it appears to more frequently develop in the olfactory cleft (7).
It could be commonly associated with nasal polyposis (NP) (8).
In a work in progress by Jankowski in 380 operated patients with nasal polyposis, REAH
or REAH-like lesions were present at pathologic examination in 18.2 %, bilateral in 62.3%.
REAH was retrospectively depicted at CT as a polyp, sometimes associated with an
enlargement of the olfactory cleft ( case 4 : fig.17-18 , case 5 : 19-20).
Surgery of nasal polyposis may not resolve nasal obstruction or anosmia if lesions
of REAH are present inside the olfactory cleft. Depiction of respiratory epithelial
adenomatoid hamartoma (REAH) with CT could also optimize surgical planning.
Olfactory neuroblastoma
Olfactory neuroblastoma is rare featuring 2-5 % of the tumors of the nasal cavity.
Mostly arises from the olfactive epithelium in the upper nasal fossa. Intracranial invasion
is frequent
Dulgerov's classification in1992 (UCLA) takes into account the distance between the
tumor and the cribriform plate in the early stages (9) :
•
•
•
•
T1 : tumor of nasal cavity with persistent airspace between tumor and the
cribriform plate
T2 : tumor in contact with the cribriform plate or sphenoid involvement
T3 : intracranial extradural invasion or orbital invasion
T4 : intracranial intradural invasion
Imaging findings in olfactory neuroblastoma are (case 6 : fig 21-24) :
-A mass
-Punctuate intratumoral calcifications (CT)
-A low signal T1 relative to brain, and a high signal T2
Page 29 of 65
-A strong enhancement after gadolinium (MR)
-Bone erosion of the cribriform plate (CT)
-An intracranial extension with cystic areas (MR)
Whole body CT and bone scan are mandatory for N and M staging because of the high
metastatic risk
Inverted papilloma (10,11)
Inverted papilloma is rare, featuring 0.4 to 4.7 % of the tumors of nasal cavity. This tumor
is benign but locally aggressive. The common site of origin is the lateral nasal wall (95%).
Coexisting squamous cell carcinoma is frequent, in about 10 %.
Imaging findings of inverted papilloma may simulate malignancy, demonstrating (case
7 : fig.25-27, case 8 : fig.28-31) :
-A mass polypoid and lobulated with a columnar pattern
-Calcifications in 4 % corresponding to entrapped bone rather than tumoral calcifications
(CT)
-A low signal on T2-weighted images (MR)
-Erosion, thinning or bowing of bone structures corresponding to pressure atrophy and
remodeling rather than frank invasion (CT)
-A mild enhancement after gadolinium
Other tumors that could arise in the sinonasal cavities
For the other various sinonasal tumors, the tumoral site in the olfactory cleft has
not been specifically mentioned, even if tumors have been sometimes located on
the lateral nasal wall or upper nasal cavity:
-SCC
Page 30 of 65
-Sinonasal undifferentiated carcinoma
-Adenoid cystic carcinoma
-Melanoma
-Lymphoma
-Plasmocytoma
-Neuroendocrine carcinoma
-Metastasis
-Paraganglioma
-Schwannoma
-Ectopic meningioma
-Osteosarcoma
-Chondrosarcoma
-Fibrosarcoma
Page 31 of 65
Images for this section:
Page 32 of 65
Fig. 1: 76 y. old man, carpenter during 50y. Nasal obstruction and epistaxis. Diagnosis
of a well differentiated adenocarcinoma of intestinal type. Obstruction of the left
ethmoidonasal cavities (arrow).
Fig. 2: 76 y. old man, carpenter during 50y. Nasal obstruction and epistaxis. Diagnosis
of a well differentiated adenocarcinoma of intestinal type. Obstruction of the left
ethmoidonasal cavities.
Page 33 of 65
Fig. 3: Coronal CT scan depicts an enlargement of the left olfactory cleft (red arrow), a
bulging of the septum (short green line)beyond the midline (blue line), and a lateral tilting
of the conchal lamina (yellow line). The origin of the tumor is inside the olfactory cleft
and not in the ethmoid.
Page 34 of 65
Fig. 4: Coronal T2-weighted image demonstrate a different signal between the tumor
(asterisk)in low signal and the ethmoidal labyrinth opacified by obstruction (yellow arrow).
The origin of the tumor is inside the olfactory cleft and not in the ethmoid.
Page 35 of 65
Fig. 5: Axial T2-weighted image demonstrate a different signal between the tumor
(asterisk)in low signal and the ethmoidal labyrinth opacified by obstruction (yellow arrow).
The origin of the tumor is inside the olfactory cleft and not in the ethmoid.
Page 36 of 65
Fig. 6: 50 y. old man, carpenter during 17y. Nasal obstruction revealing a pappilar
and mucinous adenocarcinoma of intestinal type. Obstruction of the left ethmoidonasal
cavities.
Page 37 of 65
Fig. 7: 50 y. old man, carpenter during 17y. Nasal obstruction revealing a pappilar
and mucinous adenocarcinoma of intestinal type. Obstruction of the left ethmoidonasal
cavities (yellow arrow).
Page 38 of 65
Fig. 8: Coronal CT scan depicts an enlargement of the left olfactory cleft (red line), a
bulging of the septum (green line)beyond the midline (blue line), and a lateral tilting of
the conchal lamina (yellow line). The origin of the tumor is inside the olfactory cleft and
not in the ethmoid.
Page 39 of 65
Fig. 9: Coronal T2-weighted image demonstrate a different signal between the tumor
(asterisk)in low signal and the ethmoidal labyrinth opacified by obstruction (yellow arrow).
The origin of the tumor is inside the olfactory cleft and not in the ethmoid.
Page 40 of 65
Fig. 10: Man, 72 y, retired carpenter reporting epistaxis for many weeks. ENT
examination shows evidence of haemorragic polyps at the upper part of the left nasal
cavity. Biopsy revealed adenocarcinoma of intestinal-type. CT depicts a mass filling the
left olfactory cleft (asterisk).
Page 41 of 65
Fig. 11: Man, 72 y, retired carpenter reporting epistaxis for many weeks. ENT
examination shows evidence of haemorragic polyps at the upper part of the left nasal
cavity. Biopsy revealed adenocarcinoma of intestinal-type. CT depicts a mass filling the
left olfactory cleft (asterisk).
Page 42 of 65
Fig. 12: Coronal CT scan. Elargement of the left olfactory cleft (red line) associated with
a lateral tilting of the conchal lamina (yellow line). The origin of the tumor is inside the
olfactory cleft and not in the ethmoid.
Page 43 of 65
Fig. 13: CT shows a normal air content of the ethmoid labyrinth (yellow arrow).
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Fig. 14: Coronal T2-weighted MR shows a normal air content of the ethmoid labyrinth
(arrow). The origin of the tumor is inside the olfactory cleft and not in the ethmoid.
Page 45 of 65
Fig. 15: MR show a normal air content of the ethmoid labyrinth with a low signal on T2weighted image after gadolinium (arrow)
Page 46 of 65
Fig. 16: MR show a normal air content of the ethmoid labyrinth with a low signal on T1weighted images after gadolinium (arrow)
Page 47 of 65
Fig. 17: Man of 85y., reporting nasal obstruction for many years. CT shows evidence of
an obstruction of both olfactory clefts (red asterisks). The ethmoidal labyrinth appears
with a normal air content ( yellow arrows). Biopsy revealed a bilateral respiratory epithelial
adenomatoid hamartoma (REAH).
Page 48 of 65
Fig. 18: Man of 85y., reporting nasal obstruction for many years. CT shows evidence of
an obstruction of both olfactory clefts (red arrows). The ethmoidal labyrinth appears with
a normal air content ( yellow arrows). Biopsy revealed a bilateral respiratory epithelial
adenomatoid hamartoma (REAH).
Page 49 of 65
Fig. 19: Woman of 70y. suffering from recurent sinusitis. CT performed before surgery
depicted a polyp inside the left olfactory cleft (arrow). Biopsy revealed a respiratory
epithelial adenomatoid hamartoma (REAH).
Page 50 of 65
Fig. 20: Woman of 70y. suffering from recurent sinusitis. CT performed before surgery
depicted a polyp inside the left olfactory cleft (arrow). Biopsy revealed a respiratory
epithelial adenomatoid hamartoma (REAH).
Page 51 of 65
Fig. 21: Woman of 69y. reporting unilateral left nasal obstruction for many years and an
anosmia for one month. ENT examination shows a bleeding mass. Biopsy demonstrates
an olfactory neuroblastoma. CT shows a mass of both nasal cavities (asterisk) with a
strong enhancement after contrast medium injection, responsible for lytic changes of the
septum (arrow) and turbinates.
Page 52 of 65
Fig. 22: Woman of 69y. reporting unilateral left nasal obstruction for many years and an
anosmia for one month. ENT examination shows a bleeding mass. Biopsy demonstrates
an olfactory neuroblastoma. CT shows a mass of both nasal cavities with a strong
enhancement after contrast medium injection, responsible for lytic changes of the septum
and turbinates.
Page 53 of 65
Fig. 23: T2-weighted MR shows the central location of the mass inside both olfactory
clefts (asterisks). The ethmoid labyrinth appears compressed with a high signal on T2
correponding to opacification by obstruction (arrows).
Page 54 of 65
Fig. 24: T1-weighted MR with gadolinium shows the central location of the enhancing
mass inside both olfactory clefts (asterisks). The ethmoid labyrinth appears compressed
with a partial or absence of enhancement after gadolinium (arrows).
Page 55 of 65
Fig. 25: Man of 72y. suffering from an unilateral left nasal obstruction for 2 years. Biopsy
of a left nasal mass demonstrates an inverted papilloma. The mass fills the posterior half
of the left olfactory cleft (red arrow).
Page 56 of 65
Fig. 26: Man of 72y. suffering from an unilateral left nasal obstruction for 2 years. Biopsy
of a left nasal mass demonstrates an inverted papilloma. The mass fills the posterior half
of the left olfactory cleft (red arrow) and involves the respiratory cleft inferiorly (yellow
arrow).
Page 57 of 65
Fig. 27: Man of 72y. suffering from an unilateral left nasal obstruction for 2 years. Biopsy
of a left nasal mass demonstrates an inverted papilloma. The mass fills the posterior
half of the left olfactory cleft (red arrow) and involves the whole nasal cavity posteriorly
(yellow arrow).
Page 58 of 65
Fig. 28: Man of 71y., reporting a bilateral nasal obstruction for 2 years. ENT examination
shows a mass filling the both nasal cavities. Biopsy demonstrates an inverted papilloma
with some areas of dysplasia. Axial CT scan shows an enlargement of both olfactory
clefts (red arrows), and lytic changes of the septum and turbinates (yellow arrows).
Page 59 of 65
Fig. 29: Man of 71y., reporting a bilateral nasal obstruction for 2 years. ENT examination
shows a mass filling the both nasal cavities. Biopsy demonstrates an inverted papilloma
with some areas of dysplasia. Coronal CT scan shows an enlargement of both olfactory
clefts (red arrows).
Page 60 of 65
Fig. 30: Axial T2-weighted MR demonstrates the central nasal location of the mass
involving the nasal vestibule (yellow arrowhead) with a low signal on T2 and a columnar
aspect (asterisk) and reponsible for lytic changes of the nasal septum (yellow arrow).
Page 61 of 65
Fig. 31: Axial T1-weighted MR demonstrates the central nasal location of the mass
(asterisk) involving the nasal vestibule (yellow arrowhead) with a mild enhancement after
gadolinium.
Page 62 of 65
Conclusion
There has been little concern about the olfactory cleft in the radiologic literature.
Recent observations shed light on radiologic signs (CT and MR) of tumors of the
olfactory cleft at early stage :
-Mass occupying the airspace
-Enlargement of the olfactory cleft
-Lateral tilting of the conchal lamina
-Septal bulging
-Squeezing of the ipsilateral ethmoidal labyrinth, containing air, inflammatory changes or
opacification by obstruction
Clinical applications could be suggested:
•Knowledge of tumors arising in the OC may improve the depiction of small
adenocarcinomas in woodworkers with a symptom, or Respiratory Epithelial
Adenomatoid Hamartoma in patient suffering from anosmia.
•Imaging contributes to new therapeutic approaches such as endoscopic surgery.
Page 63 of 65
Personal Information
Philippe Henrot, MD
Department of radiology
Centre Alexis Vautrin
6, ave de Bourgogne
54511 Vandoeuvre-les-Nancy
France
phone: 0033 383598341
fax: 0033 383598550
e-mail: [email protected]
References
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